The cost and cost-effectiveness of electronic discharge communication tools

A Systematic Review

Presenter: Laura Sevick, BSc, MSc Candidate

Co-authors: Rosmin Esmail, Karen Tang, Diane Lorenzetti, Paul Ronskley, Matt James, Maria Santana, William Ghali, Fiona Clement

April 11, 2016

Faculty of Medicine - Community Health Sciences

Conflicts of Interest

Nothing to disclose

Background

Transition between acute and community care is a vulnerable period in health care delivery Incidence of post discharge adverse events between 19

and 23% Vulnerability of this period has been attributed to

factors all related to the miscommunication between in-hospital and community-based physicians

Background

Traditional discharge Discharge summary is prepared by physician either by

hand or using a dictation tool Letter is signed by physician Sent to family doctor using fax or mail systems

No controls for legibility, completeness or timeliness

Background

Electronic Discharge Communication Tools (EDCTs) are one potential approach to narrowing this communication gap Two common features: (1) auto-population; (2)

electronic transmission Provide immediate link Interfaces can be designed

Background

Recent systematic review by Motamedi et al examined the efficacy of EDCTs 12 published studies in final inclusion Varied in terms of study design, study quality, and

outcome reported Cost-effectiveness not considered/reported Bottom line: support of implementing EDCTs; uncertain

if widespread implementation would be beneficial

Background

eHealth initiatives have been identified as critical components of high performing systems Potential high impacts for end-users (patients),

healthcare professionals, and data analysts

Background

Alberta deputy health minister recently announced plans to create single electronic health information system to connect acute care physicians with primary care physicians (5)

Background

eHealth initiatives are expensive: Initial cost estimate of electronic health records in

Canada - $10 Billion One consulting agency suggested number as high as

$98 Billion

Research Question

What is the cost and cost-effectiveness of EDCTs?

Study Design

Systematic review of relevant health economic literature

Research Question

PICOD

Population Pediatric and adult patients discharged* from one care provider to another

Intervention Electronic discharge communications – defined as (4):• Automatic population of a discharge document by computer databases (apps

included)• Transmission of discharge information via computer technology• Computer technology providing a ‘platform’ for dynamic discharge

communication

Comparator No comparison – including cost-analysis (no comparator)

Outcome Traditional economic evaluation and cost-analysis outcomes (ICER, cost per QALY)

Design Economic evaluations (RCT, modelling, simulation) and cost analyses

*Discharge is defined as completion of care with one provider and transitioning care to another provider

Electronic databases: MEDLINE, EMBASE, EconLit, Pubmed, National Health

Sciences Economic Evaluation Database (health economics literature)

Web of Science (IT literature) Searched in October 2015 (from inception)

No limits by year, language or human studies Reference lists of included articles reviewed

Search Strategy

Search Strategy

ECONOMIC DISCHARGE ELECTRONIC• Economic Models• Economic Evaluations• Economic Analysis• Cost-effectiveness• Cost-utility• Cost-benefit• Quality Adjusted Life

Years• Financial Analysis• Return on Investment• Value Proposition• Business care• Markov Chains

• Discharge Summary• Discharge

Communication• Patient Discharge• Transition

• Web based• Electronic• Computerized

OR

AND

Inclusion/Exclusion Criteria

INCLUSION EXCLUSION

• Economic analysis (including RCT, modelling, and simulation) or cost analysis

• Non-economic analysis

• Electronic discharge communication used as intervention

• Non-electronic communication used as intervention

• Economic evaluation of other health records (not discharge)

• Reports on economic evaluation outcomes and/or costs

• Does not report on traditional economic outcomes

• Published journal articles • Published abstracts

Methods

Abstract Review: Reviewed independently and in duplicate by two

reviewers Kappa score calculated to measure agreement

Full Text Review: Reviewed independently and in duplicate by two

reviewers Kappa score calculated to measure agreement

Data Extraction and Quality Assessment Conducted independently and in duplicate

Data Extraction and Analysis

Extraction Variables: Referred to CADTH Health Economics Guidelines 2006

o Year, country, population, outcomes, intervention, comparator, etc.

o Economic specific variables: model details (time horizon, discount rate), currency, etc.

Analysis: Descriptive component-based approach

Results: PRISMA Flow Chart

Number of records screened:1000

Number of full texts assessed for eligibility:57

Number of records excluded:943

Kappa = 0.277

Studies identified from references:

3

Number of studies included in synthesis:4

Kappa = 1.000

Number of full texts excluded:53

Abstract or poster presentation only: 7Not economic evaluation: 6Not discharge intervention: 12Discharge intervention, not summary: 23Intervention not electronic: 3Duplicate: 1Study not found: 1

Number of studies excluded from reference search:

3Not discharge intervention: 3

Author Year Country Methodological Approach Population Intervention Comparator

Kopach, R., et al, Int J Technol Assess (7) 2005 Canada Cost-effectiveness

Automation of medical

documentation for entire hospital

discharge

Speech recognition technology – signatures generated electronically,

final documents sent through email or e-fax

Dictation through telephone used to

created voice file to be transcribed – paper

based signatures and traditional mailing

Colsman, A., et al, Der Hautarzt (8) 2009 Germany Cost-analysis

Dermatology department including 4

physicians and 3 typists

Electronic medical record system combining

laboratory, experimental findings, nursing

performance indicators – separate text editor used

for writing discharge letters

Typists used to create discharge document

Aanesen, M., et al, Int J Med Inform (9) 2010 Norway Cost-benefit

10 hospital departments and

9 primary care physicians

Discharge summary created electronically and

sent electronicallyPaper based discharge

Mourad, M., et al, J Hosp Med (10) 2011 Cost-analysis

600 bed quaternary care

academic institution

Note Writer with both free-text and auto-

populated fields. Separate software tracks signatures and automatically triggers

dissemination

Orally dictated discharge notes

AuthorTitle and

abstract ( /2)

Introduction ( /1)

Methods ( /14)

Results ( /4)

Discussion ( /1)

Other ( /2)

Total ( /24)

Mourad, M., et al (2011) (10)

1 1 7 0 1 1 11

Colsman, A., et al (2009) (8) 2 1 7 1 1 0 12

Aanesen, M., et al (2010) (9) 2 1 8 2 1 0 14

Kopach, R., et al (2005) (7) 2 1 11 2 1 1 18

CHEERS Score (11):Methods: Measurement of effectiveness, Measurement of valuation of preference based outcomes, choice of model, assumptionsResults: Study parameters, characterizing uncertainty, characterizing heterogeneity

Primary Objective Primary Outcome ConclusionsKopach, R., et al (2005) (7)

Compare traditional system with dictation tool

ICER of $0.331 (in 2003 CDN $). Spending an additional $0.331 per discharge, average time of note completion decreased by one day.

Automated documentation system costs more, but reduces document completion time.

Colsman, A., et al (2009) (8)

Determine the extent to which a hospital information system for patient data supports the creation of a discharge report

Total cost per page per discharge letter in the comparator is €10.71. Total cost per page per letter in the intervention is €9.51.

Intervention is advantageous to typists but not physicians

Aanesen, M., et al (2010) (9)

Examine consequences of delayed implementation

Dynamic Net Present Value (DNPV) for 5 year implementation of electronic message exchange in hospitals and primary care units is €31.1 million.

Greater DNPV for faster implementation of electronic discharge tools

Mourad, M., et al (2011) (10)

Business case for electronic discharge communication tool

Yearly costs of discharge using current system is $496,400 (USD). Cost of a 14 day delay in billing is $107,000-$215,000 (USD).

Investing in e-discharge has real-time benefits

Results: Mourad et al

Presented business case for EDCTs Identified list of costs to consider prior to tool

adoption Infrastructure Personnel Maintenance

Modified to include time variable

Kopach, R., et al (7) Colsman, A., et al (8) Aanesen, M., et al (9) Mourad, M., et al (10) Intervention Control Intervention Control Intervention Control Intervention Control

Infrastructure + N/A Software/Licensing + N/A

Hardware + N/A Network connectivity

Server capacity for backup system

Interface with current electronic medical records

Personnel Physician champion

Physician training Computer programmer

Transcription + + + + +Deficiency tracking

Notification N/A + Postage/Dissemination + +

Maintenance + + Computer/printer

maintenance

Network maintenance Software add-ons and

updates

Time savings + + + + + + Time delays + + +

Conclusions

We identified 4 studies All were heterogeneous with respect to outcomes,

methods and quality assessment Most focused on time savings as the outcome (ICER =

$0.331, Cost per page per letter, Adoption delay, Billing delay)

Inconsistencies in how time savings was measured None of the studies measured meaningful health related

patient quality or safety outcomes Cost-effectiveness of electronic discharge tools not

often reported When reported: poor quality, important costs excluded

Limitations

Publication bias: We may have missed business cases written for electronic discharge tools

in health care o These may not be published or available to the public

Relevance of evidence: The most recent study was Mourad et al 2011 Kopach et al 2005 identified that their system would be irrelevant in 3

years

Transferability/Generalizability: Estimates are heterogeneous and quality of evidence is weak

Discussion

Infrastructure and maintenance costs not considered

Patient safety and quality measures excluded Understanding of cost-effectiveness of these tools

is limited

Future Work

Focus on traditional economic evaluation outcomes Cost-effectiveness Cost-utility

Capture costs identified as essential for adoption RCT of effectiveness with economic evaluation and

clinical measures Death Readmission Health Related Quality of Life

Acknowledgements

Funding sources:

Supervisor: Dr. Fiona Clement

Co-authors: Rosmin Esmail, Karen Tang, Diane Lorenzetti, Paul Ronskley, Matt James, Maria Santana, William Ghali

Contact: lsevick@ucalgary.ca